Intra-urban differentials in child health

This paper uses DHS data on the urban populations of Ghana, Egypt, Brazil and Thailand to investigate the effect of poverty and environmental conditions on diarrhoeal disease, nutritional status and survival among children. Differentials in health are moderate in urban Ghana, whereas in Egypt and Brazil reductions in morbidity and, above all, mortality have accrued largely to the better off. In Thailand, the poor fare better and inequalities in mortality are no larger than those in morbidity. Children’s health is affected by environmental conditions as well as by their family’s socio-economic status

Integrating HIV/STD and primary health care services : international policy developments and national responses, with special reference to South Africa.

The overall aim of this thesis was to understand how new policies are reflected in national policy, and subsequently implemented. It suggests a fruitful way of analysing how policies fare is through exploring the notion of policy transfer - a complex process, mediated by different groups of actors. The focus for this study was on one particular policy: that of integrating management of HIV and sexually transmitted diseases (STD) with primary health care (PHC) services. During the 1990s, after clinical trials showing that HIV transmission could be slowed if STDs were controlled at the PHC level, the international community strongly promoted the idea that management of HIV and STDs should be integrated into PHC services. This thesis explores the trajectory of this impetus: from policy development at international level, to the response at national level. It suggests that integration of these services was driven by strong leadership from women's groups and international donors. New technologies, such as syndromic management of STDs, were perceived to be one of the ways in which integration could be introduced at the primary level. However, reviewing such experience that exists, shows that the enthusiasm for integration of HIV/STDs with PHC services was soon tempered as limited political, financial and technical resources hindered effective implementation. The study argues that limited political interest in integration was due partly to the fact that some countries were characterised by a relatively coercive relationship between external funders and national policy makers. This meant that efforts to introduce policy reforms were not strongly supported by governments, through allocation of financial or other resources, and donors were forced to spend according to their own priorities. Thus while there was agreement at national levels to policies, in fact, at sub-national levels implementation was weak. The thesis then goes on to explore South Africa's experience, which provides a contrast to the experience of many other African countries. Relatively isolated from international discourse until the early to mid 1990s, South Africa developed its own policies on integration, reflecting many of the same concerns and interests of the international community, but generating such concern from within the country, rather than having it imposed from outside. The thesis analyses developments in policy in the country, from agenda setting to policy formulation, and then looks at what happened during implementation in the Northern Province, one of the poorest parts of South Africa, and more akin to its northern neighbours than other areas. It shows that policies were developed in a context of radical and rapid political and economic change and, as a result, national policy makers sometimes failed to take account of impediments to implementation at sub-national levels, or of the constraints to service delivery. The thesis concludes by expanding on an analytical framework for policy which incorporates the notion of policy transfer, as a necessary adjunct to understanding how policies are formulated and implemented. It suggests that where international agendas are not reflected in national policy discourse, they are less likely to be fully absorbed or implemented. However, even where policies are transferred between national and sub-national levels, problems remain with implementation which need to be addressed

Family planning and sexual health organizations: management lessons for health system reform.

Advocates of health system reform are calling for, among other things, decentralized, autonomous managerial and financial control, use of contracting and incentives, and a greater reliance on market mechanisms in the delivery of health services. The family planning and sexual health (FP&SH) sector already has experience of these. In this paper, we set forth three typical means of service provision within the FP&SH sector since the mid-1900s: independent not-for-profit providers, vertical government programmes and social marketing programmes. In each case, we present the context within which the service delivery mechanism evolved, the management techniques that characterize it and the lessons learned in FP&SH that are applicable to the wider debate about improving health sector management. We conclude that the FP&SH sector can provide both positive and negative lessons in the areas of autonomous management, use of incentives to providers and acceptors, balancing of centralization against decentralization, and employing private sector marketing and distribution techniques for delivering health services. This experience has not been adequately acknowledged in the debates about how to improve the quality and quantity of health services for the poor in developing countries. Health sector reform advocates and FP&SH advocates should collaborate within countries and regions to apply these management lessons

Planning reproductive health in conflict: a conceptual framework

A conceptual framework for planning reproductive health services for refugees is presented for use by those involved in planning field activities. Secondary sources of data are recommended to describe pre-existing patterns and trends in reproductive health status and likely determinants of any change in status, for populations which have been subsequently affected by conflict. The interaction between these patterns and the conflict itself is then analyzed, taking into account the shift in health status and service availability as the conflict progresses through various recognized phases. The potential impact of conflict is thus hypothesized in order to make initial plans for incorporating reproductive health services into standard relief packages. Two case studies are presented: Rwanda demonstrates the use of the framework in a relatively short but dramatic conflict, for which there was also substantial prior evidence on reproductive health status; Cambodia is used, in contrast, to demonstrate the use of the framework in a much more complex conflict which has been occurring over the last 20 years.Refugee Reproductive health Needs assessment Rwanda Cambodia

The political environment of HIV: lessons from a comparison of Uganda and South Africa.

Considerable interest has arisen in the role of governance or political commitment in determining the success or failure of HIV/AIDS policies in sub-Saharan Africa. During the 1990s, Uganda and South Africa both faced dramatic HIV/AIDS epidemics and also saw transformations to new political systems. However, their responses to the disease differed in many ways. This paper compares and contrasts the ways in which policy environments, particularly government structures, can impede or expedite implementation of effective HIV prevention. Four elements of these environments are discussed--the role of political leadership, the existing bureaucratic system, the health care infrastructure, and the roles assigned to non-state actors. Two common international strategies for HIV prevention, syndromic management of sexually transmitted infections and sexual behaviour change interventions, are examined in relation to these elements in Uganda and South Africa during the mid-to-late 1990s. During this period, Uganda's political system succeeded in promoting behaviour change interventions, while South Africa was more successful in syndromic management efforts. Interactions between the four elements of the policy environment were found to be conducive to such results. These elements are relatively static features of the socio-political environments, so lessons can be drawn for current HIV/AIDS policy, both in these two countries and for a wider audience addressing the epidemic

The politics of 'branding' in policy transfer: the case of DOTS for tuberculosis control.

How and why policies are transferred between countries has attracted considerable interest from scholars of public policy over the last decade. This paper, based on a larger study, sets out to explore the processes involved in policy transfer between international and national levels. These processes are illustrated by looking at a particular public health policy--DOTS for the control and treatment of tuberculosis. The paper demonstrates how, after a long period of neglect, resources were mobilised to put tuberculosis back on international and national public policy agendas, and then how the policy was 'branded' and marketed as DOTS, and transferred to low and middle income countries. It focuses specifically on international agenda setting and policy formulation, and the role played by international organisations in those processes. It shows that policy communities, and particular individuals within them, may take political rather than technical positions in these processes, which can result in considerable contestation. The paper ends by suggesting that while it is possible to raise the profile of a policy dramatically through branding and marketing, success also depends on external events providing windows of opportunity for action. Second, it warns that simplifying policy approaches to 'one-size-fits-all' carries inherent risks, and can be perceived to harm locally appropriate programmes. Third, top-down internationally driven policy changes may lead to apparent policy transfer, but not necessarily to successfully implemented programmes

Transferring policies for treating sexually transmitted infections: what's wrong with global guidelines?

The paper uses a case study of the development of syndromic management for treating sexually transmitted infections (STIs) and subsequent policies recommending worldwide use of syndromic management guidelines. These treatment policies emerged in the late 1970s from researchers and public health physicians working in sub-Saharan Africa where they had to treat large numbers of STIs in difficult circumstances. Syndromic management was initially developed in specific local epidemiological and resource situations. By the late 1980s, the World Health Organization had adopted syndromic management as policy, and began to promote it globally in the form of algorithms and training guidelines. Dissemination was assisted by the context of the rapid spread of HIV/AIDS and the apparent effectiveness of syndromic management for treating STIs and slowing the transmission of HIV/AIDS. In the mid 1990s, international donors interested in HIV control and women's reproductive health took it up, and encouraged national programmes to adopt the new guidelines. Implementation, however, was a great deal more complex than anticipated, and was exacerbated by differences between three rather separate policy networks involved in the dissemination and execution of the global guidelines. The analysis focuses on two parts of the process of policy transfer: the organic development of scientific and medical consensus around a new policy for the treatment of STIs; and the formulation and subsequent dissemination of international policy guidelines. Using a political science approach, we analyze the transition from clinical tools to global guidelines, and the associated debates that accompanied their use. Finally, we comment on the way current global guidelines need to be adapted, given the growth in knowledge

The political environment of HIV: lessons from a comparison of Uganda and South Africa

Considerable interest has arisen in the role of governance or political commitment in determining the success or failure of HIV/AIDS policies in sub-Saharan Africa. During the 1990s, Uganda and South Africa both faced dramatic HIV/AIDS epidemics and also saw transformations to new political systems. However, their responses to the disease differed in many ways. This paper compares and contrasts the ways in which policy environments, particularly government structures, can impede or expedite implementation of effective HIV prevention. Four elements of these environments are discussed--the role of political leadership, the existing bureaucratic system, the health care infrastructure, and the roles assigned to non-state actors. Two common international strategies for HIV prevention, syndromic management of sexually transmitted infections and sexual behaviour change interventions, are examined in relation to these elements in Uganda and South Africa during the mid-to-late 1990s. During this period, Uganda's political system succeeded in promoting behaviour change interventions, while South Africa was more successful in syndromic management efforts. Interactions between the four elements of the policy environment were found to be conducive to such results. These elements are relatively static features of the socio-political environments, so lessons can be drawn for current HIV/AIDS policy, both in these two countries and for a wider audience addressing the epidemic.HIV/AIDS Uganda South Africa Policy Syndromic management Sexual behaviour change

The politics of 'branding' in policy transfer: the case of DOTS for tuberculosis control

How and why policies are transferred between countries has attracted considerable interest from scholars of public policy over the last decade. This paper, based on a larger study, sets out to explore the processes involved in policy transfer between international and national levels. These processes are illustrated by looking at a particular public health policy--DOTS for the control and treatment of tuberculosis. The paper demonstrates how, after a long period of neglect, resources were mobilised to put tuberculosis back on international and national public policy agendas, and then how the policy was 'branded' and marketed as DOTS, and transferred to low and middle income countries. It focuses specifically on international agenda setting and policy formulation, and the role played by international organisations in those processes. It shows that policy communities, and particular individuals within them, may take political rather than technical positions in these processes, which can result in considerable contestation. The paper ends by suggesting that while it is possible to raise the profile of a policy dramatically through branding and marketing, success also depends on external events providing windows of opportunity for action. Second, it warns that simplifying policy approaches to 'one-size-fits-all' carries inherent risks, and can be perceived to harm locally appropriate programmes. Third, top-down internationally driven policy changes may lead to apparent policy transfer, but not necessarily to successfully implemented programmes.Policy transfer Tuberculosis DOTS Policy communities Agenda setting Public policy formulation